How I Treat How I treat postpartum hemorrhage

Primary postpartum hemorrhage (PPH), defined by the Royal College of Obstetricians and Gynaecologists as bleeding of .500 mL in the first 24 hours of childbirth, complicates 13% of deliveries. Improved awareness, better obstetric care, and involvement of multidisciplinary teams has reduced the incidence of PPH overall, but temporal trends have shown an increase inmajor obstetric hemorrhage. In theUnited Kingdom, this remains in the top 3 direct causes of maternal death; across the globe, around 73 000 women die every year from hemorrhage due to childbirth.Management requires an appreciation of the underlying cause, allowing an individualized approach, with careful consideration to appropriate choice of medical, obstetric, and hematologic intervention. Hematologists need to focus their attention on patient blood management, acute coagulopathy, hemostatic monitoring with targeted use of blood components and hemostatic agents, the impact of massive hemorrhage packs, and efficiency of product delivery. Obstetricians need to be alert to the risk factors for PPH and early predictors of worsening hemorrhage, and consider the effects of different interventions. Attention to the placental site in women with previous caesarean delivery will help with identification and management of the morbidly adherent placenta. Research shows that most maternal hemorrhagic deaths occurred where there were shortfalls in the standard of care. With modern refinements for investigation and management, this should be a feature of the past.